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32A-035 (7) Mas s ac Boara or Bui C sa e—, ;alf�cj Cmi,tructliq, M as si,,- S —ce,se: csS Boa rd O Bujd ng R egularjon s jcSa;e S111)(!I'l SpCCj;1jtN as JAY R BOLAND CSSL-101880 12 PISGAH RID HUNTINGTON MA 01050 = JAY R BOLAND 12 PISGAH RD HUNTINGTON MA 01050 12/27/2014 12/27/2ol4 1 Jay Boland C ID#2011-554 AdvPnced.4f;-Sc-alhig �4 mass save rx'Wi eff (--))? W 0)? j--." = Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164603 Type: DBA Expiration: 10/26/2015 Tr# 244106 HOME ENERGY SOLUTIONS JAY BOLAND 12 PISGAH RD. HUNTINGTON, MA 01050 Update Address and return card-Mark reason for change. Address Renewal Employment 7 Lost Card SCA 1 License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. if found return to: OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation St 164603 ration: Type: 10 Park Plaza-Suite 5170 Expiration: 10126/2015 DBA Boston,MA 02116 HOME ENERGY SOLUTIONS JAY BOLAND 12 PISGAH RD. HUNTINGTON,MA 01050 Undersecretary Not a[ t-signature - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly A-V CA b' Name(Business/Organization/Individual): r _�C ALA Address: ,�S CIZ4AN City/State/Zip: JA LA.An Q-kX-). &1(&-) Phone#: 1 -3—1e40_T 3130 Are you an employer?Check the propriate box: Type of project(required): 1.01 am an employer with 4.0 I am a general contractor and I 6.0 New construction ,prifloyees(full and/or part time).* have hired the sub-contractors 7.D Remodeling 2.U I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.D Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.+ 9.❑Building addition required] 5.OWe are a corporation and its 10.0 Electrical repairs or additions 3.01 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152, § 1(4),and we have no 12.0 Roof repairs employees.[no workers' 13.0Other comp.insurance required.] ''Any applicant that checks boa#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this boa must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. --- Insurance Company Name: C-� G (`c>CY Policy#or Self-ins.Lic.#: Expiration Date:�1" Job Site Address: ' C°.��rr NI Q. City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration(date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: , 'a Date: ( < [ t Lk Print Name: et v Phone#. L4 " (p 1 - 3(3 0 Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license M Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone M ECR OVE OWNER AUTHORIZATION FO Owner's Name) owner of the property located at (Property Address) (Property Address) hereby authorize V•' �-r rc ��t l.c�1>c� , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. �7 Owner's Whature Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: \ License Number Add ess Expiration Date A 01,Q-SD Signature Tele ne iL 9.Real d me IMDrovement Contractor: Not Applicable ❑ LSrAL � "on 160g, Company Name Registrati n Nu berms D Q'(1 �5 Address "/- Expiration Date Telephone(I(3""&O S66 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Fsigned Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[[I Brief Description of Proposed: L Work: �'�1'tSLLIOrI .� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sa. If New house and or addition to existina housing, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �C� f f l Dv L� as Owner of the subject property f n hereby authorize : t1 &11A( A to act on my beh If, in all r1bfters relative to work authorized by this building permit application. ItZ_&ad I Signature of Owner Date I, d U 2A/ 0 1 as Owner/Authorized Agent hereby d cla hat the statements and information-on-TheArigoing application are true and accurate,to the best of my knowledge and belief. Sign under the pains and penalties of perjury. Print Name f 2_J Signature of, er/, ' nt Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW k-7 YES IF YES, date issued: IF YES: Was the permit recorded at the RLegis Xry of Deeds? NO ® DONT KNOW k-.4 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW & YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO (5 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO t✓ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. -- Department use only City of Northampton Status of Permit: ilding Department Curb Cut/Driveway Permit 12 Main Street Sewer/Septic Availability A`0V ROOM 100 Water/Well Availability , �� hampton, MA 01060 Two Sets of Structural Plans ( _._phony' 587-1240 Fax 413-587-1272 Plot/Site Plans Other S a APPLICATION TO TRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit �f Zone Overlay District o Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: i2►u � L..1©Gt Name(Print) �,,I Current Mailing Address: X qa- `,Ul Telephone Signature 2.2 Authorize A ent: Name(Print) I j pi Current Mailing Address: J of Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building oc>0 0 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection �x 6. Total=0 +2+3+4+5) t>ov,,Co Check Number x This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0566 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414 PROPERTY LOCATION 71 CHERRY ST MAP 32A PARCEL 035 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tyneof Construction•_INSTALL INSULATION&AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin¢Plans Included: Owner/Statement or License 101880 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I FO ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Mmoliti ay Sig e Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. 71 CHERRY ST BP-2015-0566 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-035 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0566 Project# JS-2015-001080 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sa. ft.): 4660.92 Owner: LLOYD RICHARD&BINDA COLEBROOK Zoning. URC(100) Applicant. JAY BOLAND AT. 71 CHERRY ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214-2414 WC HUNTINGTONMA01050 ISSUED ON.1-111712014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION & AIR SEAL POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 11/17/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner